Compositions and Methods for Immunizing Against C. Difficile

ABSTRACT

This disclosure relates to methods for eliciting an immune response against C. difficile toxin A and toxin Bin an adult human subject. The subject may be at risk for a primary symptomatic C. difficile infection. In some embodiments, a method is for eliciting an immune response against C. difficile toxin A and toxin B in an adult human subject at risk for a primary symptomatic C. difficile infection, and comprises administering to the subject a composition comprising C. difficile toxoid A and toxoid B at least three times, each administration being about seven days apart.

RELATED APPLICATIONS

This application is a continuation of U.S. Ser. No. 15/645,057 filed onJul. 10, 2017, which is a continuation of U.S. Ser. No. 14/897,870 filedon Dec. 11, 2015, now U.S. Pat. No. 9,730,994 B2, which is the NationalStage Application under 35 U.S.C. § 371 of International Application No.PCT/US2014/042298 filed Jun. 13, 2014, which claims priority to U.S.Ser. No. 61/835,246 filed Jun. 14, 2013, the entire contents of whichare incorporated into this disclosure.

FIELD OF THE DISCLOSURE

This disclosure relates to methods for eliciting an immune responseagainst C. difficile toxin A and toxin B in an adult human subject(e.g., an adult human being at risk for a primary symptomatic C.difficile infection).

BACKGROUND OF THE DISCLOSURE

Clostridium difficile (C. difficile) is a gram-positive spore-forming,anaerobic bacteria. Pathological effects of C. difficile are mediated bythe secreted toxins A and B, which cause colonic mucosal injury andinflammation. Although C. difficile infection (CDI) is asymptomatic insome patients, CDI may result in acute diarrhea and colitis, and insevere cases can lead to pseudomembranous colitis and toxic megacolon.C. difficile is a clinically important cause of nosocomial diarrhea andcolitis in hospitalized patients receiving drugs that alter normal gutflora, and CDI is increasingly reported in the community. Risk factorsfor symptomatic C. difficile infection include antibiotic treatment,advanced age, underlying illness, and hospitalization or residence in along-term care facility.

Early phase clinical trials have been conducted to evaluate the safetyand immunogenicity of versions of C. difficile toxoid vaccines. Inhealthy adult (18-55 years old) and elderly (>65 years old) volunteers,an earlier evaluated C. difficile vaccine comprising toxoid A and Bproved safe and elicited an immune response to both toxin A and toxin B(Greenberg, et al. Vaccine 30: 2245-2249 (2012); Foglia, et al. Vaccine,30: 4307-4309 (2012)). The maximal dose in such studies was 50 Aig andthe toxin A to toxin B ratio 3:1. The candidate vaccine was administeredon days 0, 28 and 56. Seroconversion to toxin A was higher than toxin Bafter multiple doses in both the healthy adult and elderly volunteergroups and a more rapid decline in the antibody response in elderlysubjects as compared to the younger group was observed. Those ofordinary skill in the art recognize this as a significant problem as theelderly are often immunocomprised. The need for a C. difficile vaccinefor use in adults at risk of a symptomatic C. difficile infectioncontinues, especially in the elderly.

SUMMARY OF THE DISCLOSURE

This disclosure relates to methods for eliciting an immune responseagainst C. difficile toxin A and toxin B in an adult human subject(e.g., an adult at risk for a primary symptomatic C. difficileinfection). In some embodiments, the methods may comprise administeringto the subject a composition (e.g., a vaccine) comprising an effectiveamount of C. difficile toxoid A and toxoid B (e.g., about 40 to about500 μg/dose (w/w, total amount of toxoids A and B in the composition))at an effective toxoid A:B ratio (e.g., about any of 3:1, 3:2, or 1:1toxoid A to toxoid B by weight), and with a sufficient purity (e.g., atleast about 50 to about 100%, such as about 90-100% (w/w)), using one ormore administrations (e.g., three times) by any suitable route (e.g.,intramuscularly), each dose of a multiple dose administrationregimenbeing suitably separated from one another as may be determined byone of ordinary skill in the art as described herein (e.g., by about oneto 10 days apart such as about seven days). In one embodiment, themethod may comprise first, second and third administrations wherein thesecond administration is about seven days after the first administrationand the third administration is at least about 30 days and/or at leastabout 180 days after the first and/or second administration. Inpreferred embodiments of a multi-dose regimen, the first dose may beadministered about seven days after the first dose, and/or a third doseis administered about 30 days after the first dose (or about 20-25 daysafter the second dose). In some embodiments, the method may comprise oneor more adjuvants (e.g., an aluminum adjuvant). In certain embodiments,the method may comprise administering the composition to a human subjectat risk for infection. In some embodiments, the human subject may be atleast about any of 40, 50, 65 years or older. In some embodiments, thehuman subject may be about 40 to about 65 years of age. In someembodiments, the human subject may be about 65-75 years of age or older.In certain such embodiments, that human subject may have had, in the 12month period before the first administration, at least one or twohospital stays, each lasting at least about any of 24, 48 or 72 hours ormore, and had received systemic (not topical) antibiotics; and/or, isanticipated to have an in-patient hospitalization for a planned surgicalprocedure within 60 days of the first administration. In someembodiments, the anticipated/impending hospital stay/hospitalization maybe planned to be for 72 hours or more and may be for a surgery involvingat least one of the kidney/bladder/urinary system, musculoskeletalsystem, respiratory system, circulatory system, and/or central nervoussystem. It is preferred that the immune response elicited by thesemethods is sufficient to prevent and/or treat and/or ameliorate and/orreduce the risk of symptomatic C. difficile infection. One of ordinaryskill in the art may derive other embodiments from the descriptionprovided herein.

DETAILED DESCRIPTION

This disclosure relates to compositions and methods that may be used totreat, ameliorate, reduce the risk of, and/or prevent symptomaticinfection by C. difficile. As described above, those of ordinary skillin the art have encountered difficulty designing efficacious vaccinesagainst infections caused by C. difficile. An efficacious vaccine may beone that, for instance, treats, ameliorates, reduces the risk of, and/orprevents symptomatic infection by C. difficile. These problems have beensurprisingly solved by the compositions and methods described herein.Various embodiments of these surprisingly effective solutions aredescribed herein. Exemplary compositions are provided. For instance,compositions comprising an effective amount of C. difficile toxoid A andtoxoid B (e.g., from about 40 to about 500 μg/dose, such as about any of40, 50, 60, 70, 80, 90, 100, 110, 120, 130, 140, 150, 160, 170, 180,190, 200, 210, 220, 230, 240, 250, 260, 270, 280, 290, 300, 310, 320,330, 340, 350, 360, 370, 380, 390, 400, 410, 420, 430, 440, 450, 460,470, 480, 490, or 500 μg/dose, such as about 50 to about 100 μg/dose(w/w, total amount of toxoids A and B in the composition)) at aneffective toxoid A.B ratio (e.g., about any of 10%, 20%, 30%, 40%, 50%,60%, 70%, 3:1, 3:2, or 1:1 toxoid A to toxoid B by weight), and with asufficient purity (e.g., at least about 50 to about 100%, such as aboutany of 50, 55 60, 65, 70, 75, 80, 85, 90, 95 or 90-100% (w/w)), usingone or more administrations (e.g., three administrations or doses) byany suitable route (e.g., intramuscularly), each dose of a multiple doseadministration regimen being suitably separated from one another (e.g.,by at least about one to about ten days such as about any of one, two,three, four, five, six, seven, eight, nine or ten, such as about sevendays), are provided. The length of time (time interval) between doseswould be understood by those of ordinary skill to vary depending on theindividual and that that interval should be long enough (e.g., asmeasured in days) such that the immune response from the prior dose bothhas time to develop (e.g., to be primed) and is not in any way inhibitedby the subsequent dose (e.g., the boosting dose or doses). For example,one particular individual may require at least about seven days (e.g.,5-8 days) between doses while another may only require at least aboutfour days (e.g., 3-5 days). In some embodiments, then, the dosinginterval may vary by, for example, about 10-20%. Those of ordinary skillin the art would understand that the time between doses may need to beadjusted as described herein. In some embodiments, the secondadministration is at least one, two, three, four, five, six, seven,eight, nine or ten days after the first administration (e.g., day 0) andthe third administration is at least about 20-200 (e.g., about 20, 30,40, 50, 60, 70, 80, 90, 100, 110, 120, 130, 140, 150, 160, 170, 180,190, or 200, such as about 30 or about 180 days) days after the firstadministration. For instance, the method may comprise first, secondand/or third administrations wherein the second administration is atleast 7 days after the first administration and the third administrationis at least about 30 days and/or at least about 180 days after the firstor second administration. In some embodiments, the second administrationis about seven days after the first administration and the thirdadministration is about 30 days after the first administration. Uponadministration of such compositions using such methods to ahost/subject, an immune response is typically observed, which typicallyincludes a humoral immune response and may involve a cellular immuneresponse. In certain embodiments, the method may comprise administeringthe immunogenic composition to a human, subject at risk for infection.In some embodiments, the human subject may be at least about any of 40,50, 65 years or older. In some embodiments, the human subject may beabout 40 to about 65 years of age. In some embodiments, the humansubject may be 65-75 years of age. Thus, methods for administering thecompositions are also provided. Methods for making the compositions aredescribed herein and are available to those of ordinary skill in theart. Other embodiments will be clear from the descriptions providedherein.

This disclosure also describes methods for immunizing a subject (e.g., ahuman being) against C. difficile by administering thereto a compositioncomprising one or more antigens of C. difficile. For instance, asuitable composition may comprise a total of about 50 or about 100 g (orabout 50-100 μg) C. difficile toxoid (toxoid A and toxoid B) at anapproximate toxoid A to toxoid B ratio of about 3:2, with or withoutadjuvant (e.g., aluminum hydroxide). For comparison purposes, theantigen-containing composition may be administered to one group ofsubjects and a placebo composition (e.g., 0.9% normal saline)administered (e.g., on the same schedule) to another group.Immunological data and safety data may be obtained from the subjects onparticular days (e.g., days 0, 14, 30, 60, 180, and/or 210, and/or up to1000 days after the first administration). Administration of thecomposition may take place on, for example, days 0 (firstadministration), about day 7 (second administration), about day 30(third administration) and/or about day 180 (alternative thirdadministration or fourth administration).

As mentioned above, the composition may comprise C. difficile toxoid Aand toxoid B at an effective toxoid A:B ratio (e.g., about any of 3:1,3:2, or 1:1 toxoid A to toxoid B by weight) at a sufficient purity(e.g., about 90% or higher purity (w/w)). For instance, the compositionmay comprise a highly purified (e.g., >90% (w/w/)) preparation of C.difficile toxoids A & B in an approximate toxoid A to toxoid B ratio ofabout 3:2. Such compositions may be prepared using any of the availablemethods of preparation (e.g., as described in U.S. Prov. Appln. Ser.Nos. 61/790,423 filed Mar. 15, 2013, co-pending PCT/US2014/029035 filedMar. 14, 2014, 61/793,376 filed Mar. 15, 2013, and/or co-pendingPCT/US2014/029070 filed Mar. 14, 2014), each of which being herebyincorporated into this disclosure in their entirety). As described inthe Examples of this disclosure, toxins A and B were purified fromcultures of C. difficile, inactivated, and mixed at targeted 3:2 ratioand shown to be efficacious in inducing and/or enhancing the immuneresponse against C. difficile toxins A and B. As mentioned above,however, toxoids A and B may be combined at any effective amount and/oreffective ratio (effective indicating, for example, that an efficaciousvaccine is provided).

The term “C. difficile toxoid” is used herein to refer to a C. difficiletoxin (Toxin A or Toxin B) that has been partially or completelyinactivated. A toxin is inactivated if it has less toxicity (e.g., 100%,99%, 98%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 10% or less toxicity or anyvalue therebetween) than untreated toxin, as measured by for example anin vitro cytotoxicity assay or by animal toxicity. C. difficile toxoidscan be produced by purification of toxins from C. difficile cultures andinvativation of toxins by chemical (e.g., formaldehyde, glutaraldehyde,peroxide or oxygen treatment). Alternatively, wild type or mutant C.difficile toxins that lack or have reduced toxicity can be producedusing recombinant methods. Methods of making toxoids by genetic methodsare well know in the art. For example, mutations resulting in reducedtoxicity can be made. Wild type or mutant C. difficile toxins lackingspecific regions to reduce toxicity can also be made.

The composition, which may be a vaccine, may be provided as alyophilized formulation that may be reconstituted at the clinical sitewith diluent, and mixed with either adjuvant (e.g., an aluminum adjuvantsuch as aluminum phosphate or aluminum hydroxide or water for injection(WFI), when specified. The diluent may be, for example, anypharmaceutically acceptable diluent (e.g., 20 mM Sodium Citrate, 5%Sucrose, and 0.016% Formaldehyde; 10 niM Citrate, 4% Sucrose, 0.008%Formaldehyde, 0.57% Sodium Chloride). The adjuvant may comprise, forinstance, a suitable concentration (e.g., about any of 800-1600 μg/mL)of an adjuvant, such, as an adjuvant comprising aluminum (e.g., aluminumhydroxide or aluminum phosphate) in WFI. For instance, the adjuvant(e.g., 800-1600 g/mL aluminum hydroxide in 0.57% Sodium Chloride) may beused as the diluent to reconstitute the lyophilized formulation. WFI maybe used to dilute the lyophilized vaccine for the unadjuvantedformulations. The final dosing solution may comprise, for instance,composition/vaccine, diluent and adjuvant. As described above, placebomay also be provided as a liquid formulation (e.g., 0.9% normal saline).The volume of each delivered dose of study drug (vaccine or placebo) maybe about 0.5 mL. Formulations may be administered by any suitable route(e.g., subcutaneously, intravenously, intramuscularly,intraperitoneally, intradermally, intranodally, intranasally, orally).

The usefulness (e.g., immunogenicity) of any of the materials (e.g.,compositions) and/or methods described herein may be assayed by any ofthe variety of methods known to those o^(n)f skill in the art. Any oneor more of the assays described herein, or any other one or moresuitable assays, may be used to determine the suitability of any of thematerials described herein for an intended purpose. It is to beunderstood that these methods are exemplary and non-limiting; otherassays may also be suitable.

For instance, the compositions described herein typically induce and/orenhance the production of antibodies against C. difficile uponadministration to a subject. Such antibodies may be detected in thesubject using any of the methods available to those of ordinary skill inthe art. For instance, as described in the Examples section, serum maybe obtained from a subject and tested by ELISA to detect immunoglobulintype G (IgG) antibodies to C. difficile toxin A and/or toxin B (e.g.,“primary immunogenicity data”). Antibodies present in test sera may bereacted with toxin A or B antigens adsorbed to individual wells of amicrotiter plate. The amount of antibody bound to the antigen coatedwells may be determined using a colorimetric substrate reaction afterbinding of a secondary anti-IgG (e.g., anti-human IgG) antibody-enzymeconjugate. Substrate for the enzyme is then typically added that causescolorimetric change that was directly proportional to the antibody boundto the antigen. The concentration of antibodies in serum may be derivedby extrapolation from a standard curve, which was generated frommultiple dilutions of a reference standard serum with defined IgGunitage (ELISA unit (EU)/mL)).

A toxin neutralization assay (TNA) may also be used to quantitateneutralizing antibodies to C. difficile toxin. In this assay, serialdiluted serum may be incubated with a fixed amount of C. difficile toxinA or B. Test cells (e.g., Vero cells) may then then added andserum-toxin-cell mixture incubated under appropriate conditions (e.g.,37° C. for 6 days). The ability of the sera to neutralize the cytotoxiceffect of the C. difficile toxin may be determined by and correlated tothe viability of the cells. The assay utilizes the accumulation of acidmetabolites in closed culture wells as an indication of normal cellrespiration. In cells exposed to toxin, metabolism and CO₂ production isreduced; consequently, the pH rises (e.g., to 7.4 or higher) asindicated by the phenol red pH indicator in the cell culture medium. Atthis pH, the medium appears red. Cell controls, or cells exposed totoxin which have been neutralized by antibody, however, metabolize andproduce CO₂ in normal amounts; as a result, the pH is maintained (e.g.,at 7.0 or below) and at this pH, the medium appears yellow. Therefore,C. difficile toxin neutralizing antibodies correlate with the ability ofthe serum to neutralize the metabolic effects of C. difficile toxin oncells as evidenced by their ability to maintain a certain pH (e.g., of7.0 or lower). The color change of the media may be measured (e.g., at562 nm to 630 nm) using a plate reader to further calculate theantitoxin neutralizing antibody titer at 50% inhibition of the C.difficile toxin-mediated cytotoxicity.

In certain embodiments, it is preferred that the compositions describedherein exhibit immunogenic properties (e.g., inducing a detectableand/or neutralizing and/or protective immune response) followingappropriate administration to a subject. The presence of neutralizingand/or protective immune response may be demonstrated as described aboveand/or by showing that infection by a pathogen (e.g., C. difficile) isaffected (e.g., decreased) in individuals (e.g., human being or otheranimal) to whom the materials described herein have been administered ascompared to individuals to whom the materials have not beenadministered. For instance, one or more test subjects (e.g., human ornon-human) may be administered by any suitable route and schedule acomposition described herein, and then after a suitable amount of time(e.g., about 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 weeks) challenged by apathogenic organism. The animal(s) may be monitored for immune function(e.g., antibody production, T cell activity) following administrationand/or challenge. Sera may be analyzed for total antibody response orfor expression of particular subtypes using, for example, an antibodyELISA and/or a pathogen neutralization assay. T cell activity may bemeasured by, for example, measuring IFN-γ production afterre-stimulation with the antigen. Statistical analysis (e.g., Fisher'sexact test, Wilcoxon test, Mann-Whitney Test) may then be performed ondata to determine whether the effectiveness of the material in affectingthe immune response.

The C. difficile toxoids A and/or B as described herein may be combinedwith one or more pharmaceutically acceptable carriers to provide acomposition prior to administration to a host. A pharmaceuticallyacceptable carrier is a material that is not biologically or otherwiseundesirable, e.g., the material may be administered to a subject,without causing any undesirable biological effects or interacting in adeleterious manner with any of the other components of thepharmaceutical composition in which it is contained. The carrier wouldnaturally be selected to minimize any degradation of the activeingredient and to minimize any adverse side effects in the subject, aswould be well known to one of skill in the art. Suitable pharmaceuticalcarriers and their formulations are described in, for example,Remington's: The Science and Practice of Pharmacy, 27⁴′ Edition, DavidB. Troy, ed., Lippicott Williams & Wilkins (2005), and may beappropriate Typically, an appropriate amount of apharmaceutically-acceptable salt is used in the formulation to renderthe formulation isotonic. Examples of the pharmaceutically-acceptablecarriers include, but are not limited to, sterile water, saline,buffered solutions like Ringer's solution, and dextrose solution. The pHof the solution is generally from about 5 to about 8 or from about 7 toabout 7.5. Other carriers include sustained-release preparations such assemipermeable matrices of solid hydrophobic polymers containingpolypeptides or fragments thereof. Matrices may be in the form of shapedarticles, e.g., films, liposomes or microparticles. It will be apparentto those persons skilled in the art that certain carriers may be morepreferable depending upon, for instance, the route of administration andconcentration of composition being administered. Carriers are thosesuitable for administration to humans or other subjects.

Pharmaceutical compositions may also include thickeners, diluents,buffers, preservatives, surface active agents, adjuvants,immunostimulants. Pharmaceutical compositions may also include one ormore active ingredients such as antimicrobial agents, antiinflammatoryagents and anesthetics. Adjuvants (e.g., as described herein or as maybe otherwise available) may also be included to stimulate or enhance theimmune response.

As described above, the compositions may also comprise one or moreadjuvants. Adjuvants may be included to stimulate or enhance the immuneresponse. Non-limiting examples of suitable classes of adjuvants includethose of the gel-type (i.e., aluminum hydroxide/phosphate (“alumadjuvants”), calcium phosphate, microbial origin (muramyl dipeptide(MDP)), bacterial exotoxins (cholera toxin (CT),′ native cholera toxinsubunit B (CTB), E. coli labile toxin (LT), pertussis toxin (PT), CpGoligonucleotides, BCG sequences, tetanus toxoid, monophosphoryl lipid A(MPLA) of, for example, E. coli, Salmonella minnesota. Salmonellatyphimurium, or Shigella exseri), particulate adjuvants (biodegradable,polymer microspheres), immunostimulatory complexes (ISCOMs)),oil-emulsion and surfactant-based adjuvants (Freund's incompleteadjuvant (FIA), microfluidized emulsions (MF59, SAF), saponins (QS-21)),synthetic (muramyl peptide derivatives (murabutide, threony-MDP),nonionic block copolymers (L 121), polyphosphazene (PCCP), syntheticpolynucleotides (poly A:U, poly I:C), thalidomide derivatives(CC-4407/ACTIMID)), RH3-ligand, or polylactide glycolide (PLGA)microspheres, among others. Fragments, homologs, derivatives, andfusions to any of these toxins are also suitable, provided that theyretain adjuvant activity. Suitable mutants or variants of adjuvants aredescribed, e.g., in WO 95/17211 (Arg-7-Lys CT mutant), WO 96/6627(Arg-192-Gly LT mutant), and WO 95/34323 (Arg-9-Lys and Glu-129-Gly PTmutant). Additional LT mutants that may used include, for example,Ser-63-Lys, Ala-69-Gly, Glu-110-Asp, and Glu-112-Asp mutants. Metallicsalt adjuvants such as alum adjuvants are well-known in the art asproviding a safe excipient with adjuvant activity. The mechanism ofaction of these adjuvants are thought to include the formation of anantigen depot such that antigen may stay at the site of injection for upto 3 weeks after administration, and also the formation ofantigen/metallic salt complexes which are more easily taken up byantigen presenting cells. In addition to aluminium, other metallic saltshave been used to adsorb antigens, including salts of zinc, calcium,cerium, chromium, iron, and berilium. The hydroxide and phosphate saltsof aluminium are the most common. Formulations or compositionscontaining aluminium salts, antigen, and an additional immunostimulantare known in the art. An example of an immunostimulant is3-de-O-acylated monophosphoryl lipid A (3D-MPL). In some embodiments,the one or more adjuvants may be any one or more of an aluminum salt,emulsion, liposome, polymer, and/or a combination thereof. For instance,suitable adjuvants may include any one or more of anionic polymers,adjuvants comprising liposomes and Tolllike 7/8 receptor agonists, ethylDOPC liposomes, DC-chol, squalene emulsions comprising Toll-like 7/8receptor agonists or Toll-like 4 receptor agonists, aluminum saltscomprising Tolllike 4 receptor agonists. Certain of these compositionsmay be included in an immunogenic composition and/or vaccine (e.g., atherapeutic or preventative immunogenic composition). Other adjuvantsmay also be suitable as would be understood by those of skill in theart. Any of such adjuvants may be introduced into the composition eitherbefore, during or after the production process.

As referred to above, an immunological composition is typically one thatcomprises C. difficile antigen(s) and, upon administration to a host(e.g., an animal), induces or enhances an immune response directedagainst the antigen (and, e.g., C. difficile). Such responses mayinclude the generation of antibodies (e.g., through the stimulation of Bcells) or a T cell-based response (e.g., a cytolytic response), asdescribed above, which may be protective and/or neutralizing. Aprotective or neutralizing immune response may be one that isdetrimental to the infectious organism corresponding to the antigen(e.g., from which the antigen was derived) and beneficial to the host(e.g., by reducing or preventing infection). As used herein, protectiveor neutralizing antibodies and/or cellular responses may be reactivewith the C. difficile antigen(s) described here, especially whenadministered in an effective amount and/or schedule. Those antibodiesand/or cellular responses may reduce or inhibit the severity, time,and/or lethality of C. difficile infection when tested in animals. Asshown in the examples, the compositions described herein may be used toinduce an immune response against C. difficile. An immunologicalcomposition that, upon administration to a host, results in atherapeutic (e.g., typically administered during an active infection)and/or protective (e.g., typically administered before or after anactive infection) and/or neutralizing immune response, may be considereda vaccine.

In some embodiments, methods for preventing, ameliorating, reducing therisk of and/or treating (e.g., affecting) infection by C. difficile arealso provided. Methods for treating one or more disease conditionscaused by or involving C. difficile in a subject comprisingadministering to the subject at least one or more effective doses of acomposition described herein (e.g., comprising C. difficile antigens,e.g., toxoid A, toxoid B). The antigens may be administered in a dosageamount of about 1 to about 300 {circumflex over ( )}ig (e.g., about anyof 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 35, 40, 45, 50, 55, 60,65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 130, 140, 150, 160, 170, 180,190, 200, 210, 220, 230, 240, 250, 260, 270, 280, 290 and/or 300 g). Theantigens may be administered more than once in the same or differentdosage amounts. In certain embodiments, the C. difficile antigens may beadministered to the subject by the same or different suitable route(s)one, two, three, four, five, six, seven, eight, nine, ten, or moretimes. When multiple doses are administered, the doses may compriseabout the same or different type and/or amount of C. difficile antigensin each dose. The doses may also be separated in time from one anotherby the same or different intervals. For instance, the doses may beseparated by about any of 6, 12, 24, 36, 48, 60, 72, 84, or 96 hours,seven days, 14 days, 21 days, 30 days, 40 days, 50 days, 60 days, 70days, 80 days, 90 days, 100 days, 110 days, 120 days, 130 days, 140days, 150 days, 160 days, 170 days, 180 days, 190 days, 200 days, oneweek, two weeks, three weeks, one month, two months, three months, fourmonths, five months, six months, seven months, eight months, ninemonths, 10 months, 11 months, 12 months, 1.5 years, 2 years, 3 years, 4years, 5 years, or any time period before, after, and/or between any ofthese time periods. In some embodiments, the C. difficile antigens maybe administered alone or in conjunction with other agents (e.g.,antibiotics) Such other agents may be administered simultaneously (orabout simultaneously) with the same or different C. difficile antigens,or at a different time and/or frequency. Other embodiments of suchmethods may also be appropriate as could be readily determined by one ofordinary skill in the art.

Also provided herein are kits for administering the C. difficileantigens. In one embodiment, one or more of C. difficile antigens mayform part of and/or be provided as a kit for administration to asubject. Instructions for administering the C. difficile antigens mayalso be provided by the kit. Compositions comprising C. difficileantigens as described herein may be included in a kit (e.g., a vaccinekit). For example, the kit may comprise a first container containing acomposition described herein in dried form and a second containercontaining an aqueous solution for reconstituting the composition. Thekit may optionally include the device for administration of thereconstituted liquid form of the composition (e.g., hypodermic syringe,microneedle array) and/or instructions for use. The device foradministration may be supplied pre-filled with an aqueous solution forreconstituting the composition.

Thus, this disclosure provides compositions for providing a therapeuticor protective immune response against C. difficile, the compositioncomprising C. difficile toxoid A and toxoid B. The disclosure alsoprovides methods for administering such compositions such that an immuneresponse against C. difficile (e.g., C. difficile antigens) is inducedand/or enhanced. In certain embodiments, the compositions may furthercomprise one or more C. difficile antigens, one or more pharmaceuticallyacceptable carriers and/or one or more adjuvants (e.g., aluminum salt,emulsion, cationic liposome, anionic polymer, Toll-like receptoragonist, and a combination thereof). In some embodiments, thecompositions are immunogenic compositions and/or vaccines. Also providedare methods for immunizing a subject (such as a human being) byadministering thereto any such compositions. In some embodiments, themethods may comprise administering to the subject an immunogeniccomposition (e.g., a vaccine) comprising an effective amount (e.g., atleast about 40 to about 500, such about 50 to about 100 μg) of C.difficile toxoid A and toxoid B (combined w/w) at an effective toxoidA:B ratio (e.g., 3:1, 3:2, 1:1 by weight (w/w)), and with a sufficientpurity (e.g., at least 90% (w/w)), using one or more administrations(e.g., at least three times, each dose being suitably separated from oneanother (e.g., at least about 7 days)). An effective toxoid A:B ratio isany ratio that may be included in a composition and induce an effectiveimmune response against C. difficile toxin A and/or toxin B. In oneembodiment, the method may comprise first, second and thirdadministrations wherein the second administration is at least 7 daysafter the first administration and the third administration is at leastabout 30 days and/or at least about 180 days after the first and/orsecond administration. In some embodiments, the method may comprisefirst, second and third administrations wherein the secondadministration is about seven days after the first administration (onday 0) and the third administration is about 30 days after the firstadministration. In some embodiments, the method may comprise first,second and third administrations wherein the second administration isabout seven days after the first administration and the thirdadministration is about 180 days after the first administration. In someembodiments, the method may comprise one or more adjuvants (e.g., analuminum adjuvant). In some embodiments, the methods may enhance and/orinduce an existing immune response in a human being previously exposedto C. difficile (e.g., a seropositive human being, an anemnestic immuneresponse). In certain embodiments, human being(s) may have had, in the12 month period before the first administration, at least one or twohospital stays, each lasting at least about 24, 48 or 72 hours or more,and/or had received systemic (not topical) antibiotics; and/or, isanticipated to have an in-patient hospitalization for a planned surgicalprocedure within about 60 days of the first administration. In someembodiments, the anticipated/impending hospital stay/hospitalization maybe planned to be for about 24, 48 to 72 hours or more and may be for asurgery involving at least one of the kidney/bladder/urinary system,musculoskeletal system, respiratory system, circulatory system, andcentral nervous system. It is preferred that the immune responseelicited by these methods is sufficient to prevent and/or ameliorateand/or reduce the risk of symptomatic C. difficile infection. In certainembodiments, the method may comprise administering the immunogeniccomposition to a human subject at risk for a symptomatic infection thatis at least about 40, 50 or 65 years of age. In some embodiments, themethod may comprise administering the composition to each individual ofa group aged between about 40 and about 65 years old and/or betweenabout 65 and about 75 years old. In some embodiments, the method mayinduce about a two- to four-fold enhancement of an antibody-based immuneresponse against C. difficile toxin A and/or toxin B in about any of 80,85, 90, 95 or 100% of a population of individuals consideredseropositive before the first administration as measured by, e.g., EL1SAand/or TNA. In some embodiments, the method may induce about a two- tofour-fold enhancement of an antibody-based immune response against C.difficile toxin A and/or toxin B in about any of 20, 25, 30, 35, 40, 45,or 50% of a population of individuals considered seronegative beforeadministration of the composition, ¾s measured by, e.g., ELISA and/orTNA 14 days after the first administration (e.g., followingadministration at days 0, seven and 30). In some embodiments, the methodmay induce about a two- to four-fold enhancement of an antibody-basedimmune response against C. difficile toxin A and/or toxin B in about anyof 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, or 80% of a population ofindividuals considered seronegative before administration of thecomposition, as measured by, e.g., ELISA and/or TNA 60 days after thefirst administration (e.g., following administration at days 0, sevenand 30). In some embodiments, the individuals in such populations arefrom about 40 to about 65 years old. In some embodiments, theindividuals in such populations are from about 75 to about 65 years old.In some embodiments, this enhancement is observed about 30 days afterthe first administration (at day 0), typically follows a secondadministration at about day 7, and is typically observed before thethird administration (at, e.g., about day 30 or day 180). In someembodiments, the immune response may be detectable against toxin Aand/or toxin B for up to about 30 months (e.g., about 1000 days) afterthe first, second and/or third administration in a multiple regimenadministration protocol. In some embodiments, administration of acomposition described herein to a human subject at day 0 (firstadministration), about day 7 (second administration) and about day 30(third administration) enhances or induces an immune response against C.difficile toxin A and/or toxin B for up to about 30 months, or about1000 days as measured by, e.g., ELISA and/or TNA. In some embodiments,the level of the immune response may be about at least as high on aboutday 1000 following the first administration as on about day 14 followingthe first administration of a three dose administration regimen, asmeasured by, e.g., ELISA and/or TNA. In some embodiments, the level ofthe immune response may be about at least as high on about any of days100, 200, 300, 400, 500, 600, 700, 800, 900 and 1000 following the firstadministration as on about day 14 following the first administration asmeasured by, e.g., ELISA and/or TNA. In some embodiments, the immuneresponse may be about two- to eight-fold above baseline (e.g., antitoxinA and/or toxin B antibody levels at day 0, before the firstadministration, as measured by e.g., ELISA and/or TNA. In someembodiments, the immune response may be from about 2.5 to about 6.8-foldabove baseline as measured by e.g., ELISA and/or TNA. In someembodiments, the immune response in seropositive individuals (e.g.,non-naive) is increased from baseline by a factor of about three atabout day 7; about 10 to about 70 at about day 14; about 30 to about 200at about day 30; and about 100 to about 200 at about day 60, as measuredby ELISA for toxins A and/or B (e.g., following administration at days0, 7 and 30). In some embodiments, the immune response in seropositiveindividuals (e.g., non-naive) is increased from baseline by a factor ofabout three at about day 7; about 10 to about 100 at about day 14; about15 to about 130 at about day 30; and about 100 to about 130 at about day60, as measured by TNA for toxins A and/or B (e.g., followingadministration at days 0, seven and 30). In some embodiments, the immuneresponse in seronegative individuals (e.g., naive) is increased frombaseline by a factor of about two at about day 14; about five to about10 at about day 30; and about 25 to about 60 at about day 60, asmeasured by ELISA for toxins A and/or B (e.g., following administrationat days 0, seven and 30). In some embodiments, the immune response inseronegative individuals (e.g., naive) is increased from baseline by afactor of about two to about three at about day 14; about two to aboutfive at about day 30; and about five to about 40 at about day 60, asmeasured by TNA for toxins A and/or B (e.g., following administration atdays 0, 7 and 30). In some embodiments, the immune responses describedherein are detected in individuals considered either seropositive orseronegative at day 0 (e.g., before the first administration). In someembodiments, such immune response are detected for both C. difficiletoxin A and toxin B as measured by, e.g., ELISA and/or TNA. Methods(e.g., in vitro or in vivo) for producing such C. difficile antigens(e.g., toxoids A and/or B), and compositions comprising the same, arealso provided. Such methods may include, for example, any of thoseavailable and/or known to those of ordinary skill in the art, and/or themethods described in previously mentioned copending U.S. Prov. Appln.Ser. Nos. 61/790,423 filed Mar. 15, 2013, co-pending PCT/US2014/029035filed Mar. 14, 2014, 61/793,376 filed Mar. 15, 2013, and/or co-pendingPCT US2014/029070 filed Mar. 14, 2014). One of ordinary skill in the artmay derive other embodiments from the description provided herein.

Other embodiments are also provided as would be understood by those ofordinary skill in the art.

The terms “about”, “approximately”, and the like, when preceding a listof numerical values or range, refer to each individual value in the listor range independently as if each individual value in the list or rangewas immediately preceded by that term. The terms mean that the values towhich the same refer are exactly, close to, or similar thereto.

As used herein, a subject or a host is meant to be an individual. Thesubject can include domesticated animals, such as cats and dogs,livestock (e.g., cattle, horses, pigs, sheep, and goats), laboratoryanimals (e.g., mice, rabbits, rats, guinea pigs) and birds. In oneaspect, the subject is a mammal such as a primate or a human.

Optional or optionally means that the subsequently described event orcircumstance can or cannot occur, and that the description includesinstances where the event or circumstance occurs and instances where itdoes not. For example, the phrase optionally the composition cancomprise a combination means that the composition may comprise acombination of different molecules or may not include a combination suchthat the description includes both the combination and the absence ofthe combination (i.e., individual members of the combination).

Ranges may be expressed herein as from about one particular value,and/or to about another particular value. When such a range isexpressed, another aspect includes from the one particular value and/orto the other particular value. Similarly, when values are expressed asapproximations, by use of the antecedent about or approximately, it willbe understood that the particular value forms another aspect. It will befurther understood that the endpoints of each of the ranges aresignificant both in relation to the other endpoint, and independently ofthe other endpoint. Ranges (e.g., 90-100%) are meant to include therange per se as well as each independent value within the range as ifeach value was individually listed.

When the terms prevent, preventing, and prevention are used herein inconnection with a given treatment for a given condition (e.g.,preventing infection), it is meant to convey that the treated subjecteither does not develop a clinically observable level of the conditionat all, or develops it less frequently than he/she would have absent thetreatment. These terms are not limited solely to a situation in whichthe subject experiences no aspect of the condition whatsoever. Forexample, a treatment will be said to have prevented the condition if itis given during exposure of a subject to a stimulus that would have beenexpected to produce a given manifestation of the condition, and resultsin the subject's experiencing fewer and/or milder symptoms of thecondition than otherwise expected. A treatment can “prevent” infectionby resulting in the subject's displaying only mild overt symptoms of theinfection; it does, not imply that there must have been no penetrationof any cell by the infecting microorganism. Similarly, reduce, reducing,and reduction as used herein may be stated in connection with the riskof symptomatic infection with a given treatment (e.g., reducing the riskof a symptomatic C. difficile infection). For example, reduce, reducing,and reduction may typically refer to a subject that develops aninfection more slowly or to a lesser degree as compared to a control orbasal level of developing an infection in the absence of a treatment(e.g., administration or vaccination using antigens or compositionsdisclosed). A reduction in the risk of symptomatic infection may resultin the subject's displaying only mild overt symptoms of the infection ordelayed symptoms of infection; it does not imply that there must havebeen no penetration of any cell by the infecting microorganism.

All references cited within this disclosure are hereby incorporated byreference in their entirety. Certain embodiments are further describedin the following examples. These embodiments are provided as examplesonly and are not intended to limit the scope of the claims in any way.

EXAMPLES Example 1

A. Trial Design

A Phase H, randomized, placebo-controlled, modified double-blind(double-blind from dosage and formulation; open-label for vaccinationschedule), dose-ranging, multi-center trial in adults, was conducted.Adult subjects aged 40 to 75 years who were at risk for developing C.difficile infection during the trial because of (i) impendinghospitalization within 60 days of enrollment, or (2) current orimpending residence in a long-term care facility or rehabilitationfacility within 60 days of enrollment, were enrolled. Subjects with acurrent or prior CDI episode were excluded. Subjects were stratified byage: 40 to 65 years (50% of subjects) and 65 to 75 years (50% ofsubjects). The trial had two stages. Stage I tested 4 differentformulations of vaccine candidate and Stage II explored differentvaccination schedules using one of these formulations. In Stage I, atotal of 455 subjects were enrolled and were randomized to receive oneof the following formulations or placebo on Days 0, 7, and 30:

-   -   Group 1: Low dose (a total of 50 μg antigen (Toxoid A, Toxoid        B), with an approximate ratio of 3:2 for Toxoid A to Toxoid B)        with adjuvant (400 Aig aluminium hydroxide (ALOH));    -   Group 2: Low dose (a total of 50 μg antigen (Toxoid A, Toxoid        B), with an approximate ratio of 3:2 for Toxoid A to Toxoid B),        no adjuvant;    -   Group 3: High dose (a total of 100 μg antigen (Toxoid A, Toxoid        B), with an approximate ratio of 3:2 for Toxoid A to Toxoid B)        with adjuvant (400 μg ALOH);    -   Group 4: High dose (a total of 100 μg antigen (Toxoid A, Toxoid        B), with an approximate ratio of 3:2 for Toxoid A to Toxoid B),        no adjuvant; and,    -   Group 5: placebo (0.9% normal saline). Based on immunological        results of blood samples and safety data taken on Days 0, 14, 30        and 60, one formulation was selected for use in Stage II. In        Stage II, 206 subjects were randomized to receive 3 doses of the        selected formulation on one of two additional schedules:    -   Group 6: Days 0, 7, and 180    -   Group 7: Days 0, 30 and 180.        Results from subjects enrolled in Stage II were compared with        data obtained for subjects who received the selected vaccine        formulation on Days 0, 7 and 30 during Stage I of the study. In        Stage I, subjects were asked to provide blood samples on Days 0,        7, 14, 30, up to Day 60 and including Days 180 and 210 until a        formulation was selected. In Stage II, all subjects were asked        to provide blood samples on Days 0, 7, 14, 30, 60, 180, and 210.

The evaluated vaccine was a highly purified preparation of C. difficileToxoids A & B (in an approximate ratio of 3:2 for Toxoid A to Toxoid B).Toxins A and B were purified from cultures of C. difficile, inactivated,and mixed at targeted 3:2 ratio. The vaccine was provided as alyophilized formulation that was reconstituted at the clinical site withdiluent, and mixed with either ALOH adjuvant or water for injection(WFI), when specified. The diluent consisted of 20 mM sodium citrate, 5%sucrose, and 0.016% formaldehyde. The adjuvant consisted of 1600 μg/mLALOH in WFI. WFI was used to dilute the lyophilized vaccine for theunadjuvanted formulations. The final vaccine dosing solution consistedof vaccine and diluent and adjuvant (when necessary). Placebo wasprovided as a liquid formulation (0.9% normal saline). The volume ofeach delivered dose of study drug (vaccine or placebo) was 0.5 mL.Vaccine formulations were administered intramuscularly.

Serum was tested by EL1SA for immunoglobulin type G (IgG) antibodies toC. difficile toxin A and toxin B to generate primary immunogenicitydata. Antibodies present in test sera were reacted with toxin A or Bantigens adsorbed to individual wells of a microtiter plate. The amountof antibody bound to the antigen coated wells was determined by acolorimetric substrate reaction after the binding of a secondaryanti-human IgG antibody-enzyme conjugate. Substrate for the enzyme wasadded which caused colorimetric change that was directly proportional tothe antibody bound to the antigen. The concentration of antibodies inserum was derived by extrapolation from a standard curve, which wasgenerated from multiple dilutions of a reference standard serum withdefined 1 gG unitage (ELISA unit (EU)/mL).

A toxin neutralization assay was also used to quantitate neutralizingantibodies to C. difficile toxin. In assay, serial diluted serum wasincubated with a fixed amount of C. difficile toxin A or B. Vero cellswere then added and serum-toxin-cell mixture was incubated at 37° C. for6 days. The ability of the sera to neutralize the cytotoxic effect ofthe C. difficile toxin was determined by and correlated to the viabilityof the Vero cells. The assay utilized the accumulation of acidmetabolites in closed culture wells as an indication of normal cellrespiration. In cells exposed to toxin, metabolism and CO₂ productionwas reduced; consequently, the pH rose to 7.4 or higher as indicated bythe phenol red pH indicator in the cell culture medium. At this pH, themedium appeared red. Cell controls, or cells exposed to toxin which hadbeen neutralized by antibody, however, metabolized and produced CO₂ innormal amounts; as a result, the pH was maintained at 7.0 or below. Atthis pH, the medium appeared yellow. Therefore, C. difficile toxinneutralizing antibodies correlated with the ability of the serum toneutralize the metabolic effects of C. difficile toxin on cells asevidenced by their ability to maintain a pH of 7.0 or lower. The colorchange of the media could be measured at 562 nm to 630 nm by a platereader to further calculate the antitoxin neutralizing antibody titer at50% inhibition of the C. difficile toxin-mediated cytotoxicity. Thestudy included an observational objective namely, to describe thefirst-time occurrence of CDI episodes.

B. Stage I

Safety Assessment

There were no related SAEs or deaths reported for subjects in anytreatment group and the number of solicited or unsolicited Grade 3reactions was similar and minimal among all treatment groups. Thesolicited adverse reactions (ARs) and unsolicited AEs were generallyGrade 1 in intensity, of short duration, did not lead to studydiscontinuations and were not considered clinically significant. Therewere more solicited injection site and systemic reactions in the vaccinetreatment groups; however, the tolerability profile was acceptable andsimilar or better than the tolerability profile of other licensedvaccines. Unsolicited non-serious ARs in the SOC of general disordersand administration site conditions, specifically for unsolicitedinjection site reactions, were reported by more subjects in theadjuvanted groups than the unadjuvanted groups; however, thetolerability profile was acceptable and similar or better than thetolerability profie of other licensed vaccines. Overall, subjects in theolder age group (aged 65-75 years) did not experience increasedsolicited ARs or unsolicited AEs; the safety summary was similar to thatof younger subjects aged 40-64 years. As with the younger subjects,there were slightly more subjects who reported AEs and ARs in theadjuvanted groups; however, the tolerability profile was acceptable. Nosafety concerns were identified.

Immunogenicity Assessment

There was a treatment effect noted among all vaccine groups compared toplacebo.

ELISA Results—Geometric Mean Concentrations (GMCs)

Immune responses in all treatment groups were robust and continued toincrease at Day 60. For both toxin A and toxin B, the highest GMCs(EU/mL) in each active vaccine group were seen on Day 60, 30 days afterthe third vaccine dose. There was a consistent rise in GMCs at eachblood sampling day from Day 0 through Day 60 (Table 1). GMCs for toxin Aand toxin B increased from Day 0 to Day 60 for subjects aged 40 to 64years and subjects aged 65 to 75 years. GMCs tended to be higher forsubjects aged 65 to 75 years when vaccine with adjuvant wasadministered. The number of subjects who were seropositive (definedas >1.5 EU/mL for toxin A and >0.8 EU/mL for toxin B) at baseline washigher for toxin B than for toxin A which may represent prior exposureand/or assay sensitivity. Seropositivity at baseline enhanced the immuneresponse for toxins A and B at Day 60.

ELISA Results—Seroconversion

Group 3 subjects had the highest percentage (97.3% for toxin A and 91.8%for toxin B) of all subjects in the per-protocol population whodemonstrated a 4-fold seroconversion at Day 60 compared to Day 0. Forthe composite of toxin A and B (defined as a subject who seroconvertedfor both toxins A and B), the number and percentage of all subjects inGroup 3 who seroconverted with a >4-fold rise in IgG between Day 0 andDay 60 was 90.4% (66/73). This was higher than Group 1 (85.7%; 60/70),Group 2 (82.4%; 56/68), and Group 4 (86.1%; 62/72). For the composite oftoxin A and B, the number and percentage of subjects aged 65 to 75 yearsin Group 3 who seroconverted with a >4-fold rise in IgG between Day 0and Day 60 was 89.1% (41/46). This was higher than Group 1 (77.3%;34/44), Group 2 (71.1%; 32/45), and Group 4 (73.8%; 31/42). In the FullAnalysis Set For Immunogenicity (FAS1), for toxin A, the number andpercentage of subjects in each group who seroconverted with a >4-foldrise in IgG between Day 0 and Day 60 was as follows: Group 1 94.3%(82/87); Group 2 88.3% (83/94); Group 4 88.6% (78/88); Group 5 6.3%(3/48). For toxin B, the number and percentage of subjects in each groupwho seroconverted with a >4-fold rise in IgG between Day 0 and Day 60was as follows: Group 1 87.5% (77/88); Group 2 77.7% (73/94); Group 491.1% (82/90); Group 5 12.5% (6/48). For the composite of toxin A and B,the number and percentage of subjects in each group who seroconvertedwith a >4-fold rise in IgG between Day 0 and Days 60, 180 and 210 is setout in Table 2.

Toxin neutralization assay (TNA) Results—GMTs

For both toxin A and toxin B, the highest GMTs in each active vaccinegroup were seen on Day 60, 30 days after the third vaccine dose. Therewas a consistent rise in GMTs at each blood sampling day from Day 0through Day 60. For toxin A, GMTs were higher in Group 1 and Group 3.The highest GMTs were seen on Day 60 in Group 3. For toxin B, GMTs weresimilar in Group 1 and Group 2. GMTs were higher when high dose vaccinewas administered than when low dose was administered. The highest GMTswere seen on Day 60 in Group 4.

TNA Results—Seroconversion

For toxin A, Group 3 subjects had the highest percentage (97.3%) ofsubjects who demonstrated a 4-fold seroconversion at Day 60 compared toDay 0. Group 4 subjects had the highest percentage of subjects whodemonstrated a 4-fold seroconversion at Day 60 compared to Day 0 fortoxin B (66.2%) and for the composite of toxin A and B (63.5%). For thecomposite of toxin A and B, the number and percentage of subjects ineach group in the FASI who seroconverted with a >4-fold rise in IgGbetween Day 0 and Days 60, 180 and 210 is set out in Table 2.

Stage I Conclusion

No safety concerns were identified and thus, no treatment group waseliminated from further evaluation based on safety reasons. Results fromStage I supported the safety of the vaccine in all treatment groups.

Overall, the higher doses induced the best immune response as measuredby both ELISA and toxin neutralization assay (TNA). High-dose plusadjuvant vaccine induced the best immune response as measured by ELISA,particularly in the group aged 65 to 75 years. The high-dose plusadjuvant (Group 3) was selected for progression to Stage II as thetolerability profile was acceptable and the overall immune responseswere considered preferable, particularly in the group aged 65-75 years.As older individuals are likely to be a major portion of the targetpopulation for the administration of a vaccine against symptomatic C.difficile infection (CDI), choosing this dose is likely to provide themaximum vaccine protection.

Based on safety and immunogenicity results (including bootstrapanalyses) through Day 60 as determined during Stage I, the formulation100 μg+ALOH (Group 3) was selected as the preferred formulation to becarried forward into Stage II. This selection was influenced by thecomposite ELISA ranking analysis for all subjects in the per-protocolanalysis set for immunogenicity (PPSI). Particularly for subjects aged65 to 75 years in the full analysis set for immunogenicity (FAST), Group3 (high dose vaccine plus adjuvant) was determined to be the bestformulation. Importantly, more subjects (number and percentage) in thehigh dose plus adjuvant group demonstrated a 4-fold seroconversionbetween Day 0 and Day 60 than the other groups.

Data for Group 3 from Day 0 through Day 210, together with data forGroups 6 and 7 are presented below under heading, “Stage 2”. Followingselection of the Stage II formulation, safety data continued to becollected between Day 60 and Day 210 for Groups 1 through 5. Twoadditional blood samples were obtained for immunogenicity testing onDays 180 and 210. For Groups 1, 2, and 4, the GMCs (measured by ELISA)and GMTs (measured by TNA) for both toxin A and toxin B increased fromDay 0 through Day 60, reached a peak on Day 60, then decreased throughDay 210. However, the Day 210 values remained high compared to baseline.At Day 210 GMCs for toxin A were approximately equal to the GMCs on Day30 and GMCs for toxin B were approximately equal to GMCs On Day 14. AtDay 210 the GMTs for toxin A and toxin B were approximately half theGMTs on Day 60. GMT Day 0 baseline values were measured for each group.There were virtually no changes from baseline for GMCs or GMTs measuredin Groups 5 (placebo).

The highest >4-fold rise in seroconversion for the ELISA composite oftoxin A and B was seen on Day 60 versus Day 0 in each of Groups 1, 2,and 4. Although the seroconversion decreased after Day 60, it remainedhigh at Day 210, with 68.9% (51/74) of subjects in Group 1, 47.4%(36/76) of subjects in Group 2, and 64.9% (48/74) of subjects in Group4. The highest >4-fold rise in seroconversion for the TNA composite oftoxin A and B was seen on Day 60 versus Day 0 in each of Groups 1, 2,and 4. Although the seroconversion decreased after Day 60, it remainedhigh at Day 210, with 39.7% (29/73) of subjects in Group 1, 40.8%(31/76) of subjects in Group 2, and 58.1% (43/74) of subjects in Group4. On the basis of all Stage I data through Day 210, the overallconclusions reached after the Day 60 was that the selected formulationwas safe and immunogenic. The low dose (i.e., 50 μg/dose, toxoids A andB in a 3:2 ratio, A:B), with or without adjuvant, provided a good immuneresponse, particularly amongst the younger age group (i.e., 40-64 yearsof age).

C. Stage II

During Stage II of the study, the high dose plus adjuvant formulation(100 μg+ALOH) was evaluated using 2 additional schedules (Days 0, 7,180; and Days 0, 30, 180). Data (through Day 210) was compared to thatobtained in Group 3—that is, data was compared to that obtained in StageI in the subject group administered the same formulation using theschedule from Stage 1 (Days 0, 7, 30).

1. Safety Assessment—Overview

Overall, the vaccine formulation (100 μg+ALOH) administered at 3different schedules had an acceptable safety profile with no safetysignals identified. There were no related SAEs reported for subjects inany treatment group. The number of subjects who reported solicited orunsolicited Grade 3 reactions was similar and minimal among thetreatment groups. The solicited ARs and unsolicited AEs were generallyGrade 1 in intensity, of short duration, did not lead to studydiscontinuations, and were not considered clinically significant.Solicited reactions after any vaccine injections were reported bysimilar numbers and percentage of subjects in the 3 groups. Unsolicitednon-serious ARs (which included both injection site and systemic ARs)were reported by similar numbers and percentages of subjects in eachgroup. Subjects in the older age group (aged 65-75 years) did notexperience increased solicited ARs or unsolicited AEs; the safetysummary was similar to that of younger subjects aged 40-64 years.Overall, no safety concerns were identified.

Immunogenicity Assessment

ELISA Results

For both toxin A and toxin B, the highest GMCs (EU/mL) in Groups 3 and 7increased from Day 0 through Day 60, while in Group 6, the highest GMCwas measured on Day 30. In Group 3, the GMCs decreased at Day 210, whilein Groups 6 and 7, GMCs increased at Day 210, following a thirdvaccination at Day 180. This same pattern was seen in subjects aged 40to 64 years and subjects aged 65 to 75 years. The number of subjects whowere seropositive (defined as >1.5 EU/mL for toxin A and >0.8 EU/mL fortoxin B) at baseline was higher for toxin B than for toxin A.Seropositivity at baseline enhanced the immune response for toxins A andB at Day 60 in Groups 3 and 7 or Day 30 in Group 6.

For Groups 3 and 7 for subjects in the PPSI included in the Day 210analysis, GMCs for toxin A (measured by ELISA) increased from Day 0through Day 60, at which point they were 96.44 EU/mL and 80.37 EU/mL,respectively. For Group 6, the highest GMC before Day 210 was reached atDay 30 (rather than Day 60), at which point it was 23.33 EU/mL. In Group3, the GMCs decreased to 20.74 EU/mL at Day 210, while in Groups 6 and7, GMCs increased to 266.2 EU/mL and 252.1 EU/mL, respectively, at Day210, following a third vaccination at Day 180. For Groups 3 and 7, forsubjects in the PPSI included in the Day 210 analysis, GMCs for toxin B(measured by ELISA) increased from Day 0 through Day 60, at which pointthey were 142.1 EU/mL and 87.65 EU/mL, respectively. For Group 6, thehighest GMC before Day 210 was reached at Day 30 (rather than Day 60),at which point it was 93.59 EU/mL. In Group 3, the GMCs decreased to26.57 EU/mL at Day 210, while in Groups 6 and 7, GMCs increased to 119.6EU/mL and 124.7 EU/mL, respectively, at Day 210, following a thirdvaccination at Day 180.

There were no remarkable differences in the ELISA GMCs by subjects aged40 to 64 years and 65 to 75 years in the FASI in Groups 3, 6, and 7included in the Day 210 analysis.

For subjects who were seropositive at baseline, while baseline GMCs atDay 0 for both toxin A (3.75 EU/mL, 3.55 EU/mL, and 2.99 EU/mL) and B(8.65 EU/mL, 5.65 EU/mL, and 4.68 EU/mL), respectively, were low forsubjects in Groups 3, 6, and 7, the GMCs tended to reach higher peakvalues at Days 30 or 60 than the GMCs for subjects who were seronegativeat baseline.

At Day 60 for subjects in the PPSI included in the Day 210 analysis, thebootstrapping analysis identified Group 3 with at least 80% probabilityof being ranked number 1 for toxin B (91.5%) and the composite of toxinA and B (84.7%). At Day 60, for toxin A, an 80% probability was notreached, although Group 3 with 72.1% ranked higher than Group 6 or 7.

For toxin A (measured by ELISA) for subjects in the PPSI included in theDay 210 analysis, in Group 3, GMFR was highest (57.0) on Day 60 comparedto Day 0. In Group 6, GMFR was 14.4 on Day 30 compared to Day 0, 110.3on Day 60 compared to Day 0, but then reached 158.8 on Day 210 comparedto Day 0. In Group 7, GMFR was 48.8 on Day 60 compared to Day 0, butthen reached 1510.4 on Day 210 compared to Day 0. For toxin B (measuredby ELISA), for subjects in the PPSI included in the Day 210 analysis, inGroup 3, GMFR was highest (64.2) on Day 60 compared to Day 0. In Group6, GMFR was 43.0 on Day 30 compared to Day 0, 34.5 on Day 60 compared toDay 0, and reached 52.5 on Day 210 compared to Day 0. In Group 7, GMFRwas 23.0 on Day 30 compared to Day 0, 40.1 on Day 60 compared to Day 0,and reached 53.6 on Day 210 compared to Day 0.

ELISA Results—Seroconversion

At Day 60, for toxin A, there was a >4-fold rise in seroconversion,measured by ELISA, for 97.0% (64/66) of subjects in Group 3, 65.6%(40/61) of subjects in Group 6, and 910.2% (52/57) of subjects in Group7. (Subjects in Group 3 and Group 7 received a vaccination at Day 30;the last vaccination for Group 6 was at Day 7.) By contrast, at Day 60,for toxin B, the >4-fold rise in seroconversion, measured by ELISA, wassimilar across treatment groups: 92.4% (61/66) of subjects in Group 3,85.2% (52/61) of subjects in Group 6, and 89.5% (51/57) of subjects inGroup 7. At Day 60, for the composite of toxin A and B, there wasa >4-fold rise in seroconversion, measured by ELISA, for 90.9% (60/66)of subjects in Group 3, 60.7% (37/61) of subjects in Group 6, and 84.2%(48/57) of subjects in Group 7. A summary of the >4-fold seroconversionrates (measured by ELISA) for toxin A and B and the composite of toxin Aand B is presented Table 3 for Day 60/Day 0, Day 180/Day 0, and Day210/Day 0 in for subjects in the PPSI included in the Day 210 analysis.There were no remarkable differences in the ELISA seroconversion ratesfor subjects aged 40 to 64 years and subjects aged 65 to 75 years in theFASI in Groups 3, 6, and 7 included in the Day 210 analysis.

The percentage of subjects in the FASI included in the Day 210 analysiswho were seropositive for toxin A at baseline and who had a >4-foldseroconversion on Day 60 compared to Day 0 was 100% for subjects inGroup 3, 92.3% (12/13) of subjects in Group 6, and 87.5% (7/8) ofsubjects in Group 7. The percentage of subjects in the FASI included inthe Day 210 analysis who were seropositive for toxin B at baseline andwho had a >4-fold seroconversion on Day 60 compared to Day 0 was 94.6%(35/37) of subjects in Group 3, 910.5% (43/47) of subjects in Group 6,and 94.1% (48/51) of subjects in Group 7.

TNA Results—GMTs

For Groups 3 and 7, GMTs for toxin A and B increased from Day 0 throughDay 60. For Group 6, the highest GMT was reached at Day 30. In Group 3,the GMTs decreased at Day 210, while in Groups 6 and 7, GMTs increasedat Day 210, following a third vaccination at Day 180. This same patternwas seen in subjects aged 40 to 64 years and subjects aged 65 to 75years. The number of subjects who were seropositive at baseline washigher for toxin B than for toxin A. Seropositivity at baseline enhancedthe immune response for toxins A and B at Day 60 in Groups 3 and 7 orDay 30 in Group 6.

For Groups 3 and 7 for subjects in the PPSI included in the Day 210analysis, GMTs for toxin A (measured by TNA) increased from Day 0through Day 60, at which point they were 628.6 l/dil and 553.7 l/dil,respectively. For Group 6, the highest GMT before Day 210 was reached atDay 30 (rather than Day 60), at which point it was 158.6 l/dil. In Group3, the GMTs decreased to 270.2 l/dil at Day 210, while in Groups 6 and7, GMTs increased markedly to 8939.4 l/dil and 9015.6 l/dil,respectively, at Day 210, following a third vaccination at Day 180. ForGroups 3 and 7, GMTs for toxin B (measured by TNA) increased from Day 0through Day 60, at which point they were 466.3 l/dil and 415.0 l/dil,respectively. For Group 6, the highest GMT before Day 210 was reached atDay 30 (rather than Day 60), at which point it was 351.1 l/dil. In Group3, the GMTs decreased to 164.4 l/dil at Day 210, while in Groups 6 and7, GMTs increased to 1488.4 l/dil and 2070.3 l/dil, respectively, at Day210, following a third vaccination at Day 180.

There were no remarkable differences in TNA GMTs for toxin A or B insubjects aged 40 to 64 years and subjects aged 65 to 75 years in Groups3, 6, and 7 included in the Day 210 analysis.

For subjects who were seropositive at baseline, baseline GMTs at Day 0for toxin A were 72.07 l/dil, 44.55 l/dil, and 59.94 l/dil,respectively, and for toxin B were 161.8 l/dil, 79.31 l/dil, and 76.35l/dil, respectively for subjects in Groups 3, 6, and 7, The GMTs tendedto reach peak values many-fold higher at Days 30 or 60 than the GMTs forsubjects who were seronegative at baseline.

A TNA bootstrapping ranking analysis was performed for Groups 3, 6, and7 for subjects in the PPSI included in the Day 210 analysis (Table 4).The probability for Group 3 at Day 60, for toxin A (66.9%), toxin B(58.7%), and the composite of toxin A and B (63.0%), ranked higher thanGroup 6 or 7.

A summary of the GMFRs (measured by TNA) are presented in Table 5 forsubjects in Groups 3, 6, and 7 in the PPSI included in the Day 210analysis.

For toxin A (measured by TNA) for subjects in the PPSI in the Day 210analysis, in Group 3, GMFR was highest (310.6) on Day 60 compared to Day0. In Group 6, GMFR was 8.5 on Day 30 compared to Day 0, 6.1 on Day 60compared to Day 0, but then reached 419.8 on Day 210 compared to Day 0.In Group 7, GMFR was 26.0 on Day 60 compared to Day 0, but then reached412.6 on Day 210 compared to Day 0. For toxin B (measured by TNA) forsubjects in the PPSI in the Day 210 analysis, in Group 3, GMFR was 14.6on Day 30 compared to Day 0 and 17.0 on Day 60 compared to Day 0. InGroup 6, GMFR was 17.8 on Day 30 compared to Day 0, 13.3 on Day 60compared to Day 0, and reached 60.2 on Day 210 compared to Day 0. InGroup 7, GMFR was 14.2 on Day 30 compared to Day 0, 16.7 on Day 60compared to Day 0, and reached 70.2 on Day 210 compared to Day 0.

TNA Results—Seroconversion

At Day 60, for toxin A, there was a >4-fold rise in seroconversion for97.0% (64/66) of subjects in Group 3, 410.0% (25/61) of subjects inGroup 6, and 82.5% (47/57) of subjects in Group 7. (Subjects in Group 3and Group 7 received a vaccination at Day 30; the second vaccination forGroup 6 was at Day 7.) By contrast, at Day 60, for toxin B, the >4-foldrise in seroconversion was similar across treatment groups: 63.6%(42/66) of subjects in Group 3, 57.4% (35/61) of subjects in Group 6,and 63.2% (36/57) of subjects in Group 7. At Day 60, for the compositeof toxin A and B, there was a >4-fold rise in seroconversion for 62.1%(41/66) of subjects in Group 3, 31.1% (19/61) of subjects in Group 6,and 56.1% (32/57) of subjects in Group 7. A summary of the >4-foldseroconversion rates (measured by TNA) for the composite of toxin A andB is presented in Table 6 for Day 60/Day 0, Day 180/Day 0, and Day210/Day 0 in for subjects in the PPSI included in the Day 210 analysis.

There were no remarkable differences in the TNA seroconversion rates forsubjects aged 40 to 64 years and subjects aged 65 to 75 years in theFASI in Groups 3, 6, and 7 included in the Day 210 analysis (Appendix15, Table 15.56).

The percentage of subjects in the FASI included in the Day 210 analysiswho were seropositive for toxin A at baseline and who had a >4-foldseroconversion on Day 60 compared to Day 0 was 100% for subjects inGroup 3, 96.0% (24/25) of subjects in Group 6, and 100% of subjects inGroup 7 (Appendix 15, Table 15.59). The percentage of subjects in theFASI included in the Day 210 analysis who were seropositive for toxin Bat baseline and who had a >4 fold seroconversion on Day 60 compared toDay 0 was 96.2% (25/26) of subjects in Group 3, 100% of subjects inGroups 6 and 7. The percentage of subjects in the FASI included in theDay 210 analysis who were seronegative for toxin A at baseline and whohad a >4-fold seroconversion on Day 60 compared to Day 0 was 95.1%(78/82) of subjects in Group 3, 25.0% (17/68) of subjects in Group 6,and 80.0% (60/75) of subjects in Group 7. The percentage of subjects inthe FASI included in the Day 210 analysis who were seronegative fortoxin B at baseline and who had a >4-fold seroconversion on Day 60compared to Day 0 was 45.6% (31/68) Group 7.

Stage II Conclusion

As in Stage I, the results in Stage II continued to support the safetyof the vaccine. No safety signals were identified and the overalltolerability profile was acceptable, and comparable to Stage I.Specifically the number of subjects reporting SAEs was comparable acrossthe groups; there were no SAEs considered related to vaccination. Foursubjects died during the study, but the deaths were not consideredrelated to vaccination. Few subjects reported an AE that led to studydiscontinuation. Solicited reactions (specifically injection site painand the systemic reaction of myalgia) were somewhat higher in Group 6and 7 after the last vaccination on Day 180. Biologically significantlaboratory parameters were mostly associated with underlying medicalconditions.

The vaccine formulation at all 3 schedules was immunogenic for toxin Aand B by ELISA and TNA. Immune responses were robust and continued toincrease through Day 60 in Groups 3 and 7 and through Day 30 in Group 6.Immune responses in Group 3 remained high at Day 210. There were moresubjects who were seropositive at baseline for toxin B than for toxin A.Overall, the schedule Day 0, 7, 30 (Group 3) elicited the best immuneresponse as measured by both ELISA and TNA during the period a subjectmay be at greatest risk of CDI.

Ultimately, the optimal vaccine schedule should be consistent with arapid onset of protection during the period of pre-hospitalization,during and after hospitalization, and a high degree of compliance withthe regimen. Studies have shown that the highest risk of CDI startsaround 3 to 5 days post exposure to hospital spores. Furthermore, it hasbeen shown that 70% of CDI cases occur within 1 month of hospitaldischarge, with the remainder of cases occurring 3 months after hospitaldischarge (Premier Database). Globally the mean waiting time for plannedsurgeries has been estimated to be from 2 weeks to 5 months (31). Duringthe choice of schedule, decision ranking for the Day 60 immune responsewas given priority, since the Day 60 response should be occurring duringthe period of greatest CDI risk. While a specific correlate ofimmunologic protection is not yet known, demonstration of a good immuneresponse at Day 60 and a sustained response through Day 180 wereimportant criteria in the selection of a preferred vaccine regimen thatcould be expected to provide protection for subjects during and afterplanned hospitalization.

The vaccine formulation of 100 μg+ALOH was immunogenic for the 3 vaccineinjection schedules (Days 0, 7; 30; Days 0, 7, 180; Days 0, 30, 180)tested, at all timepoints, and for both adult (aged 40 to 64 years) andelderly (aged 65 to 75 years) subjects. Immune responses at Days 7 and14 were similar for the 3 testing schedules in adult and elderlysubjects. The ELISA GMCs and TNA GMTs were higher at Days 60 and 180 forsubjects in Group 3 than in Group 6 or 7. As expected, subjects inGroups 6 and 7 had the highest GMCs and GMTs at Day 210 because they hadbeen vaccinated 30 days prior on Day 180 (unlike subjects in Group 3).Seroconversion (measured either by ELISA or TNA) was higher on Days 60and 180 for subjects in Group 3 than in Group 6 or 7. Based on thebootstrap ranking analysis which focused principally on the immuneresponse over the first 60-day period, Group 3 was chosen as the bestschedule. Importantly, when viewed over the 180-day period (i.e., Day0+180 days=Day 180) during which maximum vaccine protection would bedesired in patients who have recently entered a defined risk period forCDI, administration of 3 doses with a 0, 7 and 30 day regimen (Group 3)overall provided the best immune response as compared with the other 2regimens (Groups 6 or 7) taking into consideration the immune responsesmeasured over Days 30, 60 and 180. This period represents a period whenpatients are likely to be of greatest risk of developing CDI. OverallGroup 3 with a vaccine schedule of Days 0, 7, and 30 produced goodimmune responses at Days 30, 60 and 180. Importantly, the results fromStage II also suggest better compliance of subjects in Group 3, as moreof these subjects received all 3 vaccine injections compared to thegroups whose third vaccine was at Day 180. It is envisioned that thevaccine would be administered in an out-patient setting, perhaps by ageneral practitioner or primary care physician, especially those whocare for the elderly or those with chronic underlying medicalconditions. Because individuals would be immunized in advance of diseaseonset, by using a Day 0, 7 and 30 vaccine schedule, a protective immuneresponse may best be achieved as early as 1 week after the secondvaccine dose (e.g., Day 14). This regimen has also been found to elicitsustained neutralizing Ab titers to both toxins A and B for at least 30months (e.g., 1000 days), with titres at or above those achieved by day14, even for seronegative individuals (e.g., naive individuals). Immuneresponses have been noted to be durable beyond 30 months for bothtoxins.

The study also revealed that day zero seropositive individuals exhibiteda greater than two- to four-fold increase in seroconversion thanseronegative individuals (e.g., naive individuals) followingvaccination. At 14 days post-vaccination (0 and 7 day dosing),seropositive individuals seroconverted (two- and four-fold increase asmeasured by ELISA or TNA) at a frequency of about two to three timesthat of seronegative individuals. At 30 days post-vaccination (about 21days after the second dose and prior to the third dose), seropositiveindividuals seroconverted (two- and four-fold increase as measured byELISA) at a higher frequency than seronegative individuals but thedifference was not as great. For instance, seroconversion as measured byELISA (Toxin A and Toxin B) was about 20-30% more frequent inseropositive individuals at day 30. As measured by TNA, seropositiveindividuals maintained a seroconversion frequency of 2-3 times that ofseronegative individuals. It is noted, however, that an increase inantibody titre was demonstrated following each dose for both baselineseropositives and seronegatives.

This regimen has also been found to elicit comparable seroconversionrates (e.g., % of subjects with a 4-fold rise from day 0 as measured byELISA) for both anti-toxin A and anti-toxin B in adult (aged 40-65years) and elderly (aged 65-75 years) subjects.

CONCLUSIONS

Results show that the vaccine at the evaluated dose levels is capable ofeliciting complete seroconversion to both toxins A and B. Such aresponse is useful for effectiveness against toxin-A negative/toxin-Bpositive C. difficile pathogenic strains, and against epidemic strainsof C. difficile that produce greater quantities of toxins A and B. Sucha response is also useful in the intended target population, whichincludes elderly individuals and subjects with diminished immunefunction. In earlier human clinical studies, a good response waselicited to toxin A but the response to toxin B was less than expected.Results show that the 100 jig dose of antigen increased theseroconversion rate to toxin B above the rates observed with the 50 μgdose. The higher dose of both toxoids A and B was associated with a morerapid response time to seroconversion to both toxins. Priority was givento Day 60 immune responses as this was the time period of greatest CDIrisk when subjects were exposed to the hospital setting per epidemiologydata. It has been determined that 70% of CDI cases occur within 30 daysof discharge from the hospital with the remainder occurring by 3 monthsafter discharge. The vaccine formulation (100 μg+ALOH) chosen afterStage I and evaluated at 3 different schedules (Days 0, 7, 30; Days 0,7, 180; Days 0, 30, 180) had an acceptable safety profile with no safetysignals identified. The vaccine when administered at different schedulesinduced a strong immune response in adult and elderly subjects asevidenced by GM measurements and seroconversion rates of IgG antibodiesand TNA results to toxins A and B. Results show that an immune responsecould be established by Day 14. The durability of the response at Day210 was also sustained. Overall, the schedule of Days 0, 7, 30 best metthe desired profile of maximum protection during the period of interestthrough Day 60. In terms of both safety and immunogenicity, thecombination of formulation (100 μg+ALOH) and schedule of Days 0, 7, 30yielded the best results.

While certain embodiments have been described in terms of the preferredembodiments, it is understood that variations and modifications willoccur to those skilled in the art. Therefore, it is intended that theappended claims cover all such equivalent variations that come withinthe scope of the following claims.

TABLE 1 Summary of ELISA GMCs, Groups 1-5 (Per-protocol analysis set forimmunogenicity, D60 analysis) Group 1 Group 2 Group 3 Low dose + adj Lowdose, no adj High dose + adj (Days 0, 7, 30) (Days 0, 7, 30) (Days 0, 7,30) Toxin (N = 70) (N = 68) (N = 73) Visit M GMC (95% CI) M GMC (95% CI)M GMC (95% CI) Toxin A IgG (ELISA - EU/mL) Day 0, V01 70 0.82 (0.76;0.88) 68 0.90 (0.78; 1.03) 73 0.92 (0.80; 1.06) Day 14, V03 69 5.17(2.91; 9.21) 68 3.90 (2.07; 7.36) 72 4.18 (2.34; 7.46) Day 30, V04 7024.37 (14.86; 39.97) 68 9.49  (5.42; 16.62) 72 17.30 (10.52; 28.43) Day60, V05 69 76.65  (51,80; 113.42) 68 59.66 (41.09; 86.61) 73 91.53 (63.30; 132.36) Toxin B IgG (ELISA - EU/mL) Day 0, V01 70 0.97 (0.71;1.31) 68 0.97 (0.68; 1.39) 73 1.32 (0.88; 1.98) Day 14, V03 70 20.34 (8.68; 47.64) 68 8.88  (3.74; 21.06) 73 19.95  (8.59; 46.35) Day 30,V04 70 47.94  (22.14; 103.81) 68 18.65  (8.23; 42.25) 73 50.66  (22.49;114.09) Day 60, V05 70 80.93  (44.95; 145.70) 68 77.90  (39.96; 151.85)73 125.3  (71.1; 221.0) Group 4 Group 5 High dose, no adj Placebo (Days0, 7, 30) (Days 0, 7, 30) Toxin (N = 73) (N = 38) Visit M GMC (95% CI) MGMC (95% CI) Toxin A IgG (ELISA - EU/mL) Day 0, V01 71 0.98 (0.83; 1.15)38 0.88 (0.76; 1.02) Day 14, V03 73 5.16 (2.76; 9.65) 38 0.93 (0.79;1.09) Day 30, V04 73 16.52  (9.02; 30.27) 38 1.19 (0.80; 1.77) Day 60,V05 73 83.12  (49.48; 139.66) 38 1.53 (0.89; 2.62) Toxin B IgG (ELISA -EU/mL) Day 0, V01 73 1.61 (1.09; 2.38) 38 0.99 (0.65; 1.52) Day 14, V0373 27.58 (11.48; 66.29) 38 1.05 (0.66; 1.66) Day 30, V04 73 53.12 (22.24; 126.87) 38 1.30 (0.71; 2.35) Day 60, V05 73 156.8  (84.2;292.2) 38 1.62 (0.79; 3.29) N: number of subjects analyzed according tothe per-protocol analysis set for immunogenicity M: number of subjectsavailable for the endpoint The 2-sided 95% CI of a geometric mean isbased on the Student t-distribution.

TABLE 2 Summary of seroconversion rates for the unselected groups (Fullanalyses set for immunogenicity, D210 analysis) Group 1 Group 2 Group 4Group 5 Low dose + adj Low dose, no adj High dose, no adj Placebo (Days0, 7, 30) (Days 0, 7, 30) (Days 0, 7, 30) (Days 0, 7, 30) (N = 94) (N =98) (N = 96) (N = 48) Visit n/M % (95% CI) n/M % (95% CI) n/M % (95% CI)n/M % (95% CI) ELISA ≥4 fold Day 60/Day 0 75/87 86.2 (77.2; 92.7) 70/9474.5 (64.4; 82.9) 75/88 85.2 (76.1; 91.9) 3/48 6.3 (1.3; 17.2) Compositerise Day 180/Day 0 56/79 70.9 (59.6; 80.6) 44/81 54.3 (42.9; 65.4) 55/8564.7 (53.6; 74.8) 1/41 2.4 (0.1; 12.9) Toxin A and Day 210/Day 0 51/7468.9 (57.1; 79.2) 36/76 47.4 (35.8; 59.2) 48/74 64.9 (52.9; 75.6) 1/372.7 (0.1; 14.2) B IgG TNA ≥4 fold Day 60/Day 0 49/88 55.7 (44.7; 66.3)47/94 50.0 (39.5; 60.5) 56/90 62.2 (51.4; 72.2) 0/48 0.0 (0.0; 7.4)Composite rise Day 180 / 36/79 45.6 (34.3; 57.2) 32/81 39.5 (28.8; 51.0)48/86 55.8 (44.7; 66.5) 0/41 0.0 (0.0; 8.6) Toxin A Day 0 and B Day 210/ 29/73 39.7 (28.5; 51.9) 31/76 40.8 (29.7; 52.7) 43/74 58.1 (46.1;69.5) 0/37 0.0 (0.0; 9.5) Day 0 N: number of subjects analyzed accordingto the full analysis set for immunogenicity. M: number of subjectsavailable for the endpoint. Seroconversion is defined as a minimum 4fold increase from the indicated visit. Exact 2-sided 95% CI for thesingle proportion is based on the Clopper-Pearson method.

TABLE 3 Summary of ELISA seroconversion rates, Groups 3, 6 and 7(per-protocol analysis set for immunogenicity, Day 210 analysis) Group 3Group 6 Group 7 High dose + adj High dose + adj High dose + adj (Days 0,7, 30) (Days 0, 7, 180) (Days 0, 30, 180) (N = 66) (N = 61) (N = 57)Toxin Visit n/M % (95% CI) n/M % (95% CI) n/M % (95% CI) Toxin A IgG Day60/Day 0 ≥4-fold rise 64/66 97.0 (89.5; 99.6) 40/61 65.6 (52.3; 77.3)52/57 91.2 (80.7; 97.1) Day 180/Day 0 ≥4-fold rise 56/66 84.8 (73.9;92.5) 31/61 50.8 (37.7; 63.9) 41/57 71.9 (58.5; 83.0) Day 210/Day 0≥4-fold rise 54/66 81.8 (70.4; 90.2) 61/61 100.0 (94.1; 100.0) 57/57100.0  (93.7; 100.0) Toxin B IgG Day 60/Day 0 ≥4-fold rise 61/66 92.4(83.2; 97.5) 52/61 85.2 (73.8; 93.0) 51/57 89.5 (78.5; 96.0) Day 180/Day0 ≥4-fold rise 49/66 74.2 (62.0; 84.2) 38/61 62.3 (49.0; 74.4) 41/5771.9 (58.5; 83.0) Day 210/Day 0 ≥4-fold rise 46/66 69.7 (57.2; 80.4)57/61 93.4 (84.1; 98.2) 53/57 93.0 (83.0; 98.1) Composite Day 60/Day 0≥4-fold rise 60/66 90.9 (81.3; 96.6) 37/61 60.7 (47.3; 72.9) 48/57 84.2(72.1; 92.5) Day 180/Day 0 ≥4-fold rise 45/66 68.2 (55.6; 79.1) 23/6137.7 (25.6; 51.0) 31/57 54.4 (40.7; 67.6) Day 210/Day 0 ≥4-fold rise41/66 62.1 (49.3; 73.8) 57/61 93.4 (84.1; 98.2) 53/57 93.0 (83.0; 98.1)N: number of subjects analyzed according to the full analysis set forimmunogenicity. M: number of subjects available for the endpoint.Composite: when a subject reaches the indicated seroconversion for bothtoxins simultaneously. Exact 2-sided 95% CI for the single proportion isbased on the Clopper-Pearson method. 2-sided 95% CI for the differenceof proportions is based on the Newcombe-Wilson score method.

TABLE 4 TNA ranking analysis for Groups 3, 6 and 7 (per-protocolanalysis set for immunogenicity, Day 210 analysis) Treatment Toxin Timepoint group Probability Toxin A Day 60 Group 3 66.9 (TNA - l/dil) Group7 33.1 Group 6 0.0 Day 14 Group 6 52.9 Group 7 44.3 Group 3 2.8 Day 210Group 7 55.6 Group 6 44.4 Group 3 0.0 Toxin B Day 60 Group 3 58.7 (TNA -l/dil) Group 7 37.6 Group 6 3.7 Day 14 Group 7 51.5 Group 6 31.9 Group 316.6 Day 210 Group 7 83.3 Group 6 16.7 Group 3 0.0 Composite Day 60Group 3 63.0 Group 7 36.6 Group 6 0.4 Day 14 Group 7 53.1 Group 6 40.7Group 3 6.2 Day 210 Group 7 69.5 Group 6 30.6 Group 3 0.0

TABLE 5 Group 3 Group 6 Group 7 High dose + adj High dose + adj Highdose + adj (Days 0, 7, 30) (Days 0, 7, 180) (Days 0, 30, 180) (N = 66)(N = 61) (N = 57) Toxin Visit M GMFR (95% CI) M GMFR (95% CI) M GMFR(95% CI) Toxin A Day 7/Day 0 66 1.7 (1.2; 2.4) 61 1.6 (1.1; 2.2) 57 1.7(1.2; 2.6) Day 14/Day 0 66 4.5 (2.6; 8.0) 61 6.2  (3.3; 11.5) 57 5.6(3.2; 9.9) Day 14/Day 7 66 2.7 (1.9; 3.9) 61 3.9 (2.4; 6.2) 57 3.2 (2.2;4.5) Day 30/Day 0 66 5.7 (3.5; 9.3) 61 8.5  (5.0; 14.7) 57 4.4 (2.6;7.3) Day 30/Day 7 66 3.4 (2.4; 4.8) 61 5.4 (3.5; 8.3) 57 2.5 (1.8; 3.4)Day 30/Day 14 66 1.2 (1.0; 1.6) 61 1.4 (1.1; 1.8) 57 0.7 (0.6; 0.9) Day60/Day 0 66 31.6 (22.8; 43.7) 61 6.1 (3.8; 9.7) 57 26.0 (16.5; 40.8) Day60/Day 30 66 5.6 (4.0; 7.7) 61 0.7 (0.6; 0.8) 57 5.9 (4.1; 8.6) Day180/Day 0 65 14.6 (11.2; 19.1) 61 4.7 (3.2; 6.9) 57 11.3  (7.5; 17.2)Day 210/Day 0 66 13.6 (10.5; 17.6) 61 419.8 (284.7; 619.0) 57 412.6(284.3; 598.7) Toxin B Day 7/Day 0 66 1.8 (1.3; 2.4) 61 2.4 (1.7; 3.4)57 2.2 (1.6; 3.2) Day 14/Day 0 66 11.9  (6.2; 22.7) 61 16.3  (8.1; 33.0)57 16.3  (7.9; 33.3) Day 14/Day 7 66 6.7  (4.0; 11.0) 61 6.8  (4.1;11.3) 57 7.2  (4.1; 12.5) Day 30/Day 0 66 14.6  (7.7; 27.6) 61 17.8 (8.9; 35.5) 57 14.2  (7.3; 27.8) Day 30/Day 7 66 8.2  (4.7; 14.0) 617.4  (4.4; 12.4) 57 6.3  (3.7; 10.8) Day 30/Day 14 66 1.2 (0.9; 1.6) 611.1 (0.9; 1.3) 57 0.9 (0.8; 1.0) Day 60/Day 0 66 17.0  (9.7; 29.7) 6113.3  (7.1; 24.7) 57 16.7  (9.0; 30.8) Day 60/Day 30 66 1.2 (1.0; 1.4)61 0.7 (0.7; 0.8) 57 1.2 (1.0; 1.4) Day 180/Day 0 66 6.8  (4.3; 10.8) 618.6  (5.1; 14.4) 57 9.0  (5.4; 14.7) Day 210/Day 0 66 6.4  (4.1; 10.0)61 60.2  (35.4; 102.2) 57 70.2  (43.0; 114.7) N: number of subjectsanalyzed according to the full analysis set for immunogenicity. M:number of subjects available for the endpoint. The 2-sided 95% CI of aGMFR is based on the Student t-distribution.

TABLE 6 Summary of TNA seroconversion rates, Groups 3, 6 and 7(per-protocol analysis set for immunogenicity, Day 210 analysis) Group 3Group 6 Group 7 High dose + adj High dose + adj High dose + adj (Days 0,7, 30) (Days 0, 7, 180) (Days 0, 30, 180) (N = 66) (N = 61) (N = 57)Toxin Visit n/M % (95% CI) n/M % (95% CI) n/M % (95% CI) Toxin A Day60/Day 0 ≥4-fold rise 64/66 97.0 (89.5; 99.6) 25/61 41.0 (28.6; 54.3)47/57 82.5 (70.1; 91.3) (TNA - 1/dil) Day 180/Day 0 ≥4-fold rise 60/6592.3 (83.0; 97.5) 27/61 44.3 (31.6; 57.6) 42/57 73.7 (60.3; 84.5) Day210/Day 0 ≥4-fold rise 58/66 87.9 (77.5; 94.6) 61/61 100.0  (94.1;100.0) 57/57 100.0  (93.7; 100.0) Toxin B Day 60/Day 0 ≥4-fold rise42/66 63.6 (50.9; 75.1) 35/61 57.4 (44.1; 70.0) 36/57 63.2 (49.3; 75.6)(TNA - 1/dil) Day 180/Day 0 ≥4-fold rise 35/66 53.0 (40.3; 65.4) 33/6154.1 (40.9; 66.9) 34/57 59.6 (45.8; 72.4) Day 210/Day 0 ≥4-fold rise34/66 51.5 (38.9; 64.0) 53/61 86.9 (75.8; 94.2) 51/57 89.5 (78.5; 96.0)Composite Day 60/Day 0 ≥4-fold rise 41/66 62.1 (49.3; 73.8) 19/61 31.1(19.9; 44.3) 32/57 56.1 (42.4; 69.3) Day 180/Day 0 ≥4-fold rise 33/6550.8 (38.1; 63.4) 21/61 34.4 (22.7; 47.7) 27/57 47.4 (34.0; 61.0) Day210/Day 0 ≥4-fold rise 31/66 47.0 (34.6; 59.7) 53/61 86.9 (75.8; 94.2)51/57 89.5 (78.5; 96.0) N: number of subjects analyzed according to thefull analysis set for immunogenicity. M: number of subjects availablefor the endpoint. Composite: when a subject reaches the indicatedseroconversion for both toxins simultaneously. Exact 2-sided 95% CI forthe single proportion is based on the Clopper-Pearson method. 2-sided95% CI for the difference of proportions is based on the Newcombe-Wilsonscore method.

1-37. (canceled)
 38. A method for eliciting an immune response againstC. difficile toxin A and C. difficile toxin B in a human subject, themethod comprising administering to the subject a composition comprisingC. difficile toxoid A and C. difficile toxoid B at a purity of about 90%or higher (w/w) at least three times, each administration being at leastabout seven days apart; optionally wherein the first administration isseparated from the second administration by about 30 days, and the thirdadministration is separated from the first administration by about 180days.
 39. A composition comprising about 100 μg of C. difficile toxoid Aand C. difficile toxoid B, optionally at an approximate ratio of 3:2;and, an adjuvant.
 40. A kit comprising: a container comprising one ormore doses of C. difficile toxoid A and C. difficile toxoid B; and,instructions for administering said doses to elicit an immune responseagainst C. difficile toxin A and C. difficile toxin B in a humansubject.